PTSD Treatment Modalities: Evidence-Based Recommendations

Trauma-Related Disorders and Recommended Treatment

Clinical Presentation of Trauma-Related Disorders and Recommended Treatments

On January 13, 2015, Andrew Brannan, a 66-year-old Vietnam veteran was executed in Georgia for killing police officer Kyle Dinkheller in 1998 (Hoffman, 2015). At the time, Brannan had been living in a bunker on his mother's property without water or electricity and had stopped taking his medications. According to the Veterans Administration (VA), he was 100% disabled due to combat-related post-traumatic stress disorder (PTSD). He also suffered from bipolar disorder, had lost two brothers to a military plane crash and suicide, and lost a father to cancer. Veterans groups, death penalty critics, and mental health advocates, all petitioned the Georgia Supreme Court for a stay of execution unsuccessfully. The veterans groups were particularly interested in preventing the death of yet another veteran who developed severe psychiatric problems while serving his or her country.

Trauma in general has affected a substantial portion of the estimated 2.6 million military personnel who have served in Iraq and Afghanistan (Ruiz, 2013). Over a million have suffered non-lethal injuries and approximately one sixth will receive a diagnosis of PTSD (Dursa, Reinhard, Barth, & Schneiderman, 2014). These figures should not be surprising given that 60 to 90% of all service members who have served in Afghanistan and Iraq have been ambushed, shot at, survived rocket or mortar attacks, or know someone who was killed or seriously injured in combat (VAHC, 2014). An unknown number have also been exposed to sexual harassment and assault.

Even if combat exposure is excluded, the American public is no stranger to trauma. As Jones and Cureton (2014) point out, close to 80% of all individuals seeking mental health services in the U.S. have suffered a traumatic event. From their perspective, trauma exposure has reached epidemic levels as the United States entered the first part of the 21st century. Among the most common sources of trauma exposure is school and community violence. Jones and Cureton (2014) also argue that trauma-induced mental health problems are among the most controversial diagnostically, second only to dissociative identity disorder. This is reflected in the substantial changes that have been made to the diagnostic boundaries, symptoms, assumptions, and clinical utility associated with a diagnosis of PTSD in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). To better understand how trauma affects mental health, recent research publications and expert opinions concerning the epidemiology, etiology, diagnosis, and treatment of PTSD, and its related disorders, will be critically reviewed here.

Trauma Epidemiology

Recent estimates suggest the prevalence of PTSD among past and current service members who saw combat in Afghanistan and Iraq is approximately 15.7%, compared to 10.9% among service members never exposed to combat (Dursa et al., 2014). By comparison, the 12-month prevalence for PTSD was 1.8 and 5.2% among civilian adult men and women, respectively; whereas, the lifetime prevalence of PTSD among adult men and women is 3.6 and 9.7%, respectively (Gradus, 2014). These rates have been stable since the early 90s, but based on these statistics, simply serving in the military without combat exposure increases the risk of developing PTSD substantially.

PTSD prevalence rates, however, tends to hide important considerations from a clinical perspective. According to a recent study, American civilians least likely to seek mental health services for trauma in Southern California are male, African-American, poor, and lack mental health literacy (Ghafoori, Barragan, & Palinkas, 2014). More troubling was the finding that the higher the number of trauma exposures the less likely mental health services will be accessed. The most common traumatic events reported included physical assault and abuse, mugging, robbery, being threatened with a weapon, or being involved in a life-threatening accident. Interestingly, study participants with a history of sexual assault were more likely to have sought mental health services. In terms of mental disorder diagnosis, between 40 and 50% of study participants met the criteria for PTSD, generalized anxiety disorder (GAD), and/or depression. Reported symptoms included emotional pain, avoidance, irritability, sadness, anxiety, hopelessness, and depression. The psychosocial effects included unemployment, economic stress, and social problems. Among the reasons given for not seeking treatment was anxiety over unwanted side effects of medication and having to revisit the traumatic event(s).

Etiology and Diagnosis

Trauma- and stressor-related disorders is an umbrella classification for any psychological disorder where a diagnosis requires trauma exposure or severe stress as part of the etiology (APA, 2013, p. 265). This includes PTSD, acute stress disorder, reactive attachment disorder, disinhibited social engagement disorder, and adjustment disorders. Individuals can react to traumatic or extremely stressful events in a variety of ways, besides clinically severe anxiety or fear, such as anhedonia, dysphoria, anger, aggression, and/or dissociation. The current PTSD diagnostic criteria for anyone over the age of 6 includes direct or secondhand exposure to a traumatic event, avoidance behaviors, negative affect and behaviors, sleep problems, impaired social or occupational functioning, and/or intrusive memories, dreams, somatic reactions, or reliving of the event (APA, 2013, pp. 271-280). Secondhand exposure for anyone over the age of 6 is limited to witnessing an unnatural or threatened death, serious injury, medical catastrophe, war, disasters, or sexual assault involving another person, or learning of a close family member or friend experiencing unnatural death, serious injury, sexual assault, disaster, or suicide. Exposure to trauma through news and electronic media is excluded diagnostically, unless the exposure is required by work-related obligations. When a child 6-years of age or younger is exposed to trauma indirectly the person traumatized must be a caregiver to meet PTSD diagnostic criteria. A diagnosis of PTSD is appropriate when symptoms last for more than a month and cannot be attributed to a medical condition or pharmacological agents (APA, 2013, pp. 271-280). A PTSD diagnosis may earn a qualifier if manifestation of symptoms is delayed for months or accompanied by dissociative symptoms.

The traumas experienced directly that can trigger PTSD symptoms include combat, actual or threatened physical assault, actual or threatened sexual violence, kidnapping/hostage/prisoner of war, torture, severe automotive accident, or exposure to a terrorist attack, natural disaster, or man-made disaster (APA, 2013, p. 274). More specifically, diagnostically-relevant traumas include criminal victimization, rape, abusive sexual contact, sexual harassment, sexual trafficking, and experiencing sudden, catastrophic medical events, such as waking during surgery or anaphylactic shock. In children, merely experiencing developmentally-inappropriate sexual events in the absence of violence or injury can elicit clinically-relevant symptoms. When the trauma is inflicted intentionally by another person the symptoms are often severe and long-lasting. Obvious examples if the intentional infliction of trauma would be torture and sexual assault.

PTSD Clinical Presentation

The traumatic events that can lead to a diagnosis of PTSD are quite diverse, as are the diversity of clinical presentations. Among the most prominent features are intrusive memories, dreams, somatic symptoms, and flashbacks (APA, 2013, pp. 275-276). During flashbacks, a person may enter a limited or complete dissociative state, lasting from a few seconds to days, and engage in behaviors more appropriate for the relived event. Unfortunately, flashbacks can be nearly as traumatic as the real event and lead to prolonged states of distress and arousal. Flashbacks are often triggered by an otherwise innocuous event. Examples include combat veterans hearing a car backfire or a hurricane survivor walking outside on a windy day. Triggering events also include somatic sensations. For example, a physical assault victim with a traumatic brain injury may re-experience the assault should they begin to feel dizzy.

To avoid being re-traumatized by flashbacks, trauma victims quickly learn behaviors intended to avoid triggering situations and events (APA, 2013, pp. 275-276). This leads to the development of a repertoire of avoidance behaviors, which is one of the diagnostic criteria for PTSD. These behaviors include deliberate attempts to minimize exposure to thoughts, feelings, memories, discussions, activities, objects, situations, or individuals that might trigger a flashback, which explains why individuals with low mental health literacy fail to take advantage of mental health services when made available (Ghafoori et al., 2014). Negative cognitions become more prominent and can include inaccurate generalizations about society, others, or self, such as always having bad judgment, authority figures can never be trusted, or all men are sexual predators (APA, 2013, pp. 275-276). Inaccurate attributions may become entrenched in a trauma victim's thought processes and can include beliefs, for example, that sexual victimization could have been avoided if the victim had behaved differently. Other cognitive manifestations of trauma include dissociative amnesia, poor concentration, memory impairments, and sleep problems due to elevated arousal. Depersonalization and derealization may be evident, which are dissociative states in relation to the victim's body or reality, respectively. In children, cognitive alterations may include loss of language ability, while some adult trauma victims may experience auditory hallucinations and paranoia. Victims that experience prolonged, severe, repetitive exposures to trauma, such as childhood sexual assault or torture, will have difficulty regulating emotions, developing and maintaining stable relationships, and/or avoiding dissociative states. Such victims have been suggested to be suffering from what the World Health Organization considers to be complex PTSD (CPTSD) (Wolf et al., 2015).

Negative cognitions often co-occur with negative mood alterations and may include persistent states of fear, anxiety, horror, shame, guilt, and anger (APA, 2013, pp. 275-276). Anhedonia, social detachment, dysphoria, and dysthymia may also be prominent. Emotional regulation may be compromised, leading to the development of a quick temper, aggressive behaviors, or violent behaviors against objects, self, or others. Self-harming behaviors include substance abuse, unsafe sex, and taking unnecessary risks when driving. Another prominent feature of trauma exposure includes hypervigilance against anticipated threats related or unrelated to the traumatic event. A victim of an almost fatal motor vehicle accident, for example, may develop an exaggerated fear of other life-threatening events or situations, such as having a sudden heart attack. Trauma victims may also have an elevated startle response, resulting in what most people would see as being jumpy.

PTSD symptoms can manifest as early as the second year of life and typically within three months of trauma exposure (APA, 2013, pp. 276-279). The most common pattern is for some symptoms to develop immediately, resulting in a clinical diagnosis of acute stress disorder. With the passage of months or even years, however, additional symptoms may develop that meet the diagnostic criteria for PTSD. The symptoms of acute stress disorder are essentially the same as for PTSD, but manifestation and resolution of acute stress disorder symptoms must occur within one month of trauma exposure. By comparison, manifestation of PTSD may take months and years and resolution is similarly uncertain; however, resolution for some individuals may be as short as within 3 months of the trauma exposure, while the symptoms for others may persist for decades. Clinical presentation may also be aggravated by the aging process in older adults, due to declining health. Aging following trauma exposure may moderate symptoms to some extent, but young adults exposed to the same trauma as older adults will tend to cope better with symptoms if they develop.

Children may experience scary dreams with content unrelated to the traumatic event (APA, 2013, p. 277). When awake, children may report experiencing symptoms during play and may not display negative affect during flashbacks or when exposure to the trauma occurred; however, parents may report noticing behavioral and negative mood changes. During play, children may create imagined interventions and engage in avoidance behaviors. Avoidance behaviors may manifest as restricted age-appropriate activities. Avoidance behaviors in adolescents will emerge as a reluctance to pursue developmental milestones, such as learning to drive or beginning to date. Negative cognitive changes may include seeing oneself as cowardly, socially undesirable, and without a promising future. The negative emotional changes include short tempers, aggression, irritability, recklessness, and thrill-seeking, which increase the risk of harm to self and others.

PTSD Risk Factors

Not everyone exposed to trauma will develop PTSD symptoms. For example, exposure to combat elicited PTSD symptoms in 15.7% of American troops serving in Iraq or Afghanistan (Dursa et al., 2014). This statistic implies that some individuals are predisposed to developing trauma-related mental health issues compared to others. Some of these risk factors include age, such that younger adults will more likely develop symptoms when compared to older adults (APA, 2013, pp. 277-278). A history of childhood emotional problems manifesting before age 6 is another risk factor, as is prior exposure to traumatic events. A history of externalizing behaviors, anxiety problems, panic disorder, depression, obsessive-compulsive disorder, and PTSD are all risk factors. Low socioeconomic status, cultural traditions, academic achievement, race/ethnicity, family mental health history, genetics, social isolation, and cognitive impairment are factors that can modify risk. In addition, the severity and duration of trauma exposure are important determinants, as are poor coping strategies in the aftermath of exposure.

Comorbidity

Comorbidity is very common among PTSD patients (APA, 2013, p. 280). Major depression, bipolar, anxiety, and substance abuse disorders are among the most common. The prevalence of mild traumatic brain injury among Iraq and Afghanistan War veterans suffering from PTSD, for example, was found to be 48%. Comorbidity among children, however, is distinct from adult patterns, with oppositional defiant and separation anxiety disorders representing the most common conditions. Major neurocognitive disorder is closely related to delirium and dementia, but many of the symptoms for this disorder are often shared with PTSD sufferers, resulting in a dual diagnosis.

PTSD Controversy

The prevalence of PTSD comorbidities should not be surprising since most mental disorders emerge within patients having a history of adversity (Paris, 2013, p. 125). Biological and social factors also contribute to the prevalence of trauma-related disorders; therefore, the etiological complexity of PTSD undermines the common belief that authors of diagnostic manuals understand PTSD etiology, at least according to Joel Paris (2013). From his perspective, it is more useful to consider the fact that most people exposed to trauma do not develop PTSD and those who do, have had mental health issues in the past. The 12-month PTSD prevalence rate of 1.8 and 5.2% for adult U.S. men and women (Gradus, 2014), respectively, supports Paris's (2013) argument, since an estimated 25% of the U.S. population in 2004 reported suffering from a mental illness during the preceding year (Reeves et al., 2011, p. 1).

The DSM published by the American Psychiatric Association (APA) has included PTSD for the past three editions, but the diagnostic criteria have expanded with each revision (Paris, 2013, p. 126). According to Paris (2013) the increasingly inclusive diagnostic criteria undermine research efforts and encourage clinicians to make incorrect associations between symptoms and past events. For example, the most common reaction to trauma exposure is resilience and recovery; therefore, it is important to consider the underlying personality traits that modify the risk of developing PTSD. Paris (2013) further criticized the inclusion of dissociative and aggression symptoms in the latest DSM version, DSM-5, because these symptoms can also manifest in individuals suffering from personality disorders. Paris (2013) recommends that clinicians limit PTSD diagnoses to individuals whose lives have been truly compromised by flashbacks and avoidance behaviors lasting months and years. According to the DSM-5, the functional consequences of PTSD include severe social, occupational, and physical disability (APA, 2013, p. 279) and may include suicide ideation and attempts. The possibility of personality disorders representing an important and prevalent predisposing factor for PTSD development, however, has been undermined by the findings of a recent empirical study examining more than a dozen adults suffering from PTSD and childhood trauma (Thornback, Muller, & Rosenkranz, 2014). Based on their analysis, personality disorder features were not predictive of trauma treatment efficacy and trauma recovery occurred despite persistent personality disorder features.

Evidence-Based Treatment (EBT) Approaches

Over 250 VA clinical staff providing mental health services to veterans in 38 residential treatment programs were asked about the efficacy of different treatment modalities (Cook et al., 2014). The occupations of study participants included psychiatrist, psychologist, social worker, nurse, and administrator. The greatest consensus was reached in favor of evidence-based treatment (EBT) and milieu therapy, which 25 and 23% of participants, respectively, believed provided the greatest reductions in PTSD symptoms for combat veterans. By comparison, only 5 and 4% of participants believed psychoeducation and cognitive restructuring, respectively, were effective, despite considerable effort to promote these EBT approaches system-wide. Cognitive restructuring is an important element of cognitive processing therapy (CPT), an approach that has been shown repeatedly to be among the most effective treatment paradigms for PTSD.

Milieu therapy attempts to create an environment within which healing from trauma can take place, primarily by offering practical coping strategies (Lawson, 1998). The five components of milieu therapy are "containment, structure, support, involvement, and validation" (p. 100). Containment is possible when clinicians are able to create a place of safety, within which trauma victims can come to terms with their experiences. The clinician traits needed for this to happen include being knowledgeable, empathic, and physically strong without being intimidating. Clinicians must also be on guard against secondary trauma and employ methods of social interactions that create and maintain barriers; barriers designed to help a child, teenager, or adult feel safe. Signs of successful containment include reductions in aggression, suicidal ideation, suicide attempts, and PTSD symptomology. A well-structured schedule helps traumatized children and adolescents begin to manage their emotions and circadian rhythms appropriately, learn to self-soothe, develop independence, and replace aggression with assertive discussion. Reaching these milestones is essential for beginning trauma recovery work. Support, involvement, and validation address PTSD symptoms by encouraging engagement in recovery activities. Common barriers include dissociation, fear of intimacy, and intolerance towards self due to perceived shortcomings. The benefits include improved self-esteem, healthy social risk-taking, reduced social anxiety, engagement in social activities, and resilience in the face of adversity.

Milieu therapy creates a therapeutic environment, within which a diverse array of therapeutic approaches can be implemented. Cognitive processing therapy, a form of cognitive behavioral therapy (CBT), has received a lot of attention as an evidenced-based therapy for U.S. combat veterans and adult survivors of childhood abuse suffering from PTSD. A recent meta-analysis revealed large and significant effect sizes for studies comparing trauma-focused CBT with wait-listed adult survivors of childhood abuse or treatment as usual (Ehring et al., 2014, p. 653). Trauma-focused CBT is designed to directly confront and work through trauma memories, in part by learning about PTSD symptoms, minimizing dissociation from internal experiences, developing the skills needed to cope with trauma-associated thoughts and feelings, and understanding how trauma changes a person's beliefs about the world in which they live. The authors of this study concluded that contrary to popular opinion, trauma-focused treatments do not put patient safety at risk by dredging up trauma memories. Based on their analysis, trauma-focused therapies are superior and the dropout rate of patients is similar to other therapeutic modalities.

A meta-analysis of studies examining the efficacy of treatment modalities for combat veterans suffering from PTSD revealed similar findings. The most consistent support among studies incorporating a control group was for exposure therapies, while a single controlled study examining CBT vs. wait-listed veterans revealed a large effect size consistent with other published findings (Goodson et al., 2011). The effect sizes for non-controlled studies using CBT or CPT were also large. In a separate study, VA clinicians favored EBT interventions for treating PTSD (25%), yet survey results revealed only 4 and 7.5% believed in vivo exposure and trauma processing groups, respectively, to be effective (Cook et al., 2014). These studies revealed significant problems with translating empirical findings into clinical practice.